ST.

MARY’S COLLEGE OF TAGUM, INC SMCTI

OFFICE OF THE RESEARCH ETHICS COMMITTEE
National Highway, Tagum City, 8100 Davao del Norte, Philippines
Email Address: smctirec@smctagum.edu.ph
QTIME
Faith • Excellence • Service
Quality Transformative Ignacian Marian Education

IMPORTANT NOTICE TO THE PRINCIPAL INVESTIGATORS:

1. This is the Informed Consent Form developed by the SMCT Research Ethics Committee to
better facilitate the principal investigators in the design of their Informed Consent Form (ICF),
Informed Assent Form (IAF), and Parental Informed Consent Form (PICF). You may use
alternative wording in the formulation of your ICF, IAF, and PICF.

2. The ICF, IAF, or PICF consists of two (2) essential parts, namely: (a) The Participation
Information Sheet and the Certificate of Consent. Both of these are conditions sine qua non
before your protocol be reviewed and/or before you can conduct your research study.

3. Explanations in red-italicized words or paragraphs are for your information and guidance and
should be deleted from the actual ICF. However, the black-printed ones are mandated texts.

4. The ICF should be accomplished in two (2) copies: (a) one copy for the participant to keep;
and (2) one copy for the researcher to keep on file.
 ST. MARY’S COLLEGE OF TAGUM, INC SMCTI
OFFICE OF THE RESEARCH ETHICS COMMITTEE
National Highway, Tagum City, 8100 Davao del Norte, Philippines
Email Address: smctirec@smctagum.edu.ph
QTIME
Faith • Excellence • Service
Quality Transformative Ignacian Marian Education

INFORMED CONSENT FORM

PARTICIPATION INFORMATION SHEET

DEAR PARTICIPANT/S:

I, _____________________________, a graduate student of St. Mary’s College of Tagum,

Inc. taking up Master of Arts in Education major in ____________________ _________________.
I am currently conducting my research study entitled
_____________________________________________________________________.

I am asking for your written and duly signed informed consent to this research study. The
purpose of your participation in this research study is to help the principal investigator
_____________________________ (Why this research study is to be conducted? Provide a
general statement of purpose of the research study). You are chosen as a possible participant in
this research study based on the following criteria: ___________________________________.
(Indicate why you have chosen and recruited this participant in your research study. Remember,
people may wonder why they have been chosen and perhaps may be fearful, confused or
concerned.)

Please feel free to read the following information carefully and feel free to ask the above-
named principal investigator if there is anything that is not clear to you or if you need more
information and guidance. You must be eighteen (18) years of age or older to participate in this
research study.

SIGNATORY AND WITNESS/PROXY CONTENT

There is nobody except you is required to sign the consent form to signify your
participation in the research study. However, if you are unable to read and/or write, you may
select somebody to accompany you during the reading and explanation of the informed consent
form and sign the same in your behalf.

No witness is required in order for the consent form to be binding nor is a proxy content
allowed. But if you are below eighteen (18) years of age, a parental informed consent from your
parent or legal authorized representative and your informed assent are needed before you can
fully participate in this research study.

PURPOSE, OBJECTIVES & SIGNIFICANE OF THE STUDY

The purpose of the study is to (here, kindly explain in layman’s terms why you are doing
this research study (i.e., research questions – not necessarily that you are going to copy in toto
the Statement of the Problem). Also state the aim/s or objective/s and a short explanation of the
significance of the study. The language used should clarify rather than confuse. Use simplified
words and phrases rather than scientific or esoteric terms. To better facilitate you, find substitutes
for such terms, you may seek aid from Google or any other internet terminology platform guides.
 ST. MARY’S COLLEGE OF TAGUM, INC SMCTI
OFFICE OF THE RESEARCH ETHICS COMMITTEE
National Highway, Tagum City, 8100 Davao del Norte, Philippines
Email Address: smctirec@smctagum.edu.ph
QTIME
Faith • Excellence • Service
Quality Transformative Ignacian Marian Education

RESEARCH STUDY PROCEDURES

If you agree to participate in this research study, the following

will occur: (State your process step by step with detail and include the approximate amount of
time the process will take. This includes the length of time for the IDI, FGD, survey questionnaire,
or experiment. You should include information on interview or questionnaire topics, any personal
information requested, data collection methods (audio, video, written) and frequency (if more than
one collection). You also state the member checking mechanism.

VOLUNTARY PARTICIPATION AND ALTERNATIVE OPTIONS

Your decision whether or not to participate in this research study is completely voluntary. It
is up to you whether or not you decide to participate. If you decide to participate, you will be
required to sign this informed consent form. After you sign this consent form, you can still
withdraw your consent and discontinue participation at any time and without giving a reason. In
the event that you withdraw from the study before data collection is completed, rest assured that
your data be destroyed in a manner prescribed by law.

RISKS, BENEFITS, REMUNERATION, AND REIMBURSEMENTS

There are no known risks in participating in this study (If there are identified risks, you
must state what they are, e.g. being uncomfortable, embarrassed, and/or inconvenienced are
risks). There are no direct benefits to participation in this research study, however, your
participation will help _________________ (explain the knowledge to be gained from this
research study and/or how the study will contribute to the discipline or field. If in case there are
direct benefits to the participants, it must be clearly stated). You will be given a simple token of
gratitude for the time you spent as a participant in the study. You will also be recompensed of
whatever expenses that you may have incurred in the conduct of the study. (Travel expenses,
compensation for loss of income, meal expenses, internet load, cellphone load, etc.).

PRINCIPAL INVESTIGATOR’S RESPONSIBILITY DURING ADVERSE SITUATIONS

The principal investigator should state the scope and limitation of the study, i.e., the
number and kind of participants and the procedures (IDI, FGD) of gathering information. In the
event that there will be occurrence of potential harm (e.g., psychological, emotional, financial, or
social), as the principal investigator, how do you deal with these adverse situations during the
actual conduct of the research study (i.e, IDI, FGD)? This concerns the responsibility of the
principal investigator to ensure that mechanisms on how to address the occurrence of any type of
harm during the research study shall be dealt with accordingly.

It is, therefore essential that you, as principal investigator (a) behave according to
appropriate ethical standards; (b) consider how your research might negatively affect your
participants; and (c) protect yourself, your adviser, and your institution from placed in situations in
which individuals could make claims of inappropriate behavior, resulting in public criticism or even
your being sued. (Polonski, 2004, p. 53)

In order to avoid the occurrence of any potential type of harm (i.e., psychological,
emotional or social) during the conduct of this research study, I will provide you in advance with
information on counseling matters or services or appropriate support bodies (if necessary) dealing
with the issue. But in the event that interaction with you may inadvertently harm you in some
 ST. MARY’S COLLEGE OF TAGUM, INC SMCTI
OFFICE OF THE RESEARCH ETHICS COMMITTEE
National Highway, Tagum City, 8100 Davao del Norte, Philippines
Email Address: smctirec@smctagum.edu.ph
QTIME
Faith • Excellence • Service
Quality Transformative Ignacian Marian Education
unintended way, I will take responsibility to address the issue. (You
may expound this portion if you wish to.)

PRIVACY AND CONFIDENTIALITY

Your privacy is of paramount importance, and thus, it is protected by conducting the

research in private setting and/or other space consideration or security measures will be properly
observed for online research/survey platforms. Equally, you should not be forced to reveal any
personal information to the researcher that you do not wish to reveal.

Rest assured that the data or information you provide will be treated with complete
anonymity and utmost confidentiality by means of discrete coding. No individual identities will be
used in any reports, presentations or publications resulting from the research study. All research
data or information will be kept in locked files at all times (for material copies) or password
protected folder (for electronic copies). Only the principal investigator will have access to the files.

After the research study is completed, the data collected will be retained for three (3) years
and be destroyed immediately thereafter in a secure manner that would prevent unauthorized
access, use or disclosure to any other party or the public or in a manner prescribed by law.

(Note: If in case the research data will be disclosed to other party, there must be an explanation
of the procedure by which the extent that such research data will be disclosed and to whom).

STUDY RELATED INJURIES (This is applicable only to researches wherein the amount of risks
is inevitable.)

For studies with more than minimal risk, you must explain whether any medical treatments are
available if injury occurs and, if so, what they consist of, or where further information may be
obtained. Consent forms cannot include any exculpatory language that which the subject is made
to appear to waive any legal rights or releases the researcher or institution from liability for
negligence.

INFORMATION AND STUDY RESULTS

You may have access to your own data. After the analysis of all the data for this research
and you wanted to be informed of the results, you will be provided with a free copy of the results.
(You may copy this one or expound depending upon the context of your research study.)

USE OF RESEARCH DATA

The data collected from this research study will be used solely for the attainment of the
intended purposes. It may be presented at any research fora and/or published in journals or used
for any other legitimate purposes, which St. Mary’s College of Tagum considers proper in the
interest of education, knowledge, or research. (You may expound this portion based on your
research context.)

AUTHORSHIP

I am the only author of this study. (You may expound this portion according to your
research context.)
 ST. MARY’S COLLEGE OF TAGUM, INC SMCTI
OFFICE OF THE RESEARCH ETHICS COMMITTEE
National Highway, Tagum City, 8100 Davao del Norte, Philippines
Email Address: smctirec@smctagum.edu.ph
QTIME
Faith • Excellence • Service
Quality Transformative Ignacian Marian Education

CONFLICT OF INTEREST

I declare no conflict of interest. (If there exists any conflict of interests such as but not
limited to relationship to any members of the Technical Committee and/or Research Ethics
Committee; or you hold a position (for example as a principal) in an academic institution that may
wish to restrict or otherwise manage adverse research findings for commercial reasons.

PUBLICATION

Results of the study may be submitted for publication. The study may be presented in a
scientific forum or published in a journal, but in a manner where your personal identity will not be
revealed. (If there is a plan and a timeline for the sharing of information, include the details. The
participant may also be informed that the research findings will be shared more broadly, for
example, through publications and conferences.)

CONTACT INFORMATION

If you have questions about the study, please feel free to the contact the above-named
principal investigator by calling __________________________ or email him/her at
______________________________. You can also contact the Chairperson of the SMCT
Research Ethics Committee, Dr. Maria Lalaine P. Chieng at ___________________ with any
questions about your rights as a research participant or any related research concerns or contact
the Data Protection Officer, Mr. Erwin L. Sabornido at 09324858115 or email him at
erwinsabornido@smctagum.edu.ph or smctagumdpc@gmail.com for concerns regarding your
data privacy rights.

Thank you very much!

 ST. MARY’S COLLEGE OF TAGUM, INC SMCTI
OFFICE OF THE RESEARCH ETHICS COMMITTEE
National Highway, Tagum City, 8100 Davao del Norte, Philippines
Email Address: smctirec@smctagum.edu.ph
QTIME
Faith • Excellence • Service
Quality Transformative Ignacian Marian Education

CERTIFICATE OF CONSENT

I have read and understood the provided information, or it has been read to me. I have
had given the opportunity to ask questions about it and any questions I have been asked have
been answered to my satisfaction. I understand that I will be given a copy of this form, and the
researcher will keep another copy on file. I hereby consent voluntarily to be a participant in this
study.
Please check the option that applies to you before affixing your signature below with the following
options: (This is mandatory.)
I give permission for my ________________________ to be audio or video taped.
I do not give permission for my ____________________ to be audio or video taped.

For face-to-face conduct of research: (This is optional.)

I have been informed about the risk of exposure to COVID-19 in this research study. I
understand that regardless of any precautions taken, a possible risk of exposure to the virus
still exists.
(This is mandatory)
Printed Name of the Participant : ____________________________________________
Signature of the Participant : ____________________________________________
Date & Place : ____________________________________________

This portion is applicable only to participant/s who is/are illiterate:

I have witnessed the accurate reading of the consent form to the potential participant, and
the individual has had the opportunity to ask questions, I confirm that the individual has given
consent freely and voluntarily. Thumb Print of the Participant

Printed Name of the Witness : _____________________________

Signature of the Witness : _____________________________
Date & Place : _____________________________

Note: A literate witness must sign on behalf of the illiterate participant (if possible, he/she should
be selected by the participant and should have no connection to the principal investigator/s).
Participant/s who is/are illiterate should include their thumb-print as well.

Statement by the Principal Investigator/s Taking Consent (This is mandatory).

I, the undersigned, certify that to the best of my knowledge, the participant signing this
consent form has read the above information sheet fully or it has been read to him or her and that
this has been carefully explained to him or her and that he or she clearly understands the nature
of the risks and benefits of his or her participation in this study. I confirm that the participant has
not been coerced into giving consent, and the consent has been given freely and voluntarily.

A copy of this Informed Consent Form has been provided to the participant. (This is
mandatory.)
Printed Name of the Principal Investigator : ______________________________________
Signature of the Principal Investigator : ______________________________________
 ST. MARY’S COLLEGE OF TAGUM, INC SMCTI
OFFICE OF THE RESEARCH ETHICS COMMITTEE
National Highway, Tagum City, 8100 Davao del Norte, Philippines
Email Address: smctirec@smctagum.edu.ph
QTIME
Faith • Excellence • Service
Quality Transformative Ignacian Marian Education
Date & Place :
______________________________________